Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees.

BACKGROUND: Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. METHODS: All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). RESULTS: There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. CONCLUSIONS: The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Outpatient Total Joint Arthroplasty at a High-Volume Academic Center: An Analysis of Failure to Launch.

BACKGROUND: Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center. METHODS: All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD. RESULTS: Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830). CONCLUSIONS: With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Cushing's Syndrome in a Pregnant Patient Secondary to Adrenal Adenoma: Treatment With Unilateral Adrenalectomy.

BACKGROUND: A pregnant woman presented with Cushing's syndrome (CS) secondary to adrenal adenoma and was treated with laparoscopic-assisted right adrenalectomy during the second trimester of pregnancy. SUMMARY: Our patient is a 33-year-old woman who presented with hypertension and cushingoid appearance at 21 weeks gestational age. Laboratory evidence indicated CS was likely, and imaging found a 2.3 x 3.0 cm right adrenal nodule as a suggested cause. Laparoscopic-assisted right adrenalectomy was performed at 23 weeks 4 days gestation without complication. Pathology of the removed specimen revealed an adrenal gland containing a 3.0 x 3.0 x 2.0 cm well-circumscribed proliferation of adrenal cortical cells without significant atypia. This report describes the rare occurrence of CS during pregnancy and subsequent successful surgical management. We review the diagnosis of CS during pregnancy and surgical considerations. CONCLUSION: CS, while a rare entity in the general population, is even more unique in the setting of pregnancy due to the negative effects of hypercortisolism on fertility. CS during pregnancy presents a diagnostically complicated scenario, along with specific considerations necessary for successful surgical management.

Pneumatosis Cystoides Intestinalis Identified on Screening Colonoscopy With Associated Pneumoperitoneum.

Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures.